Wednesday, September 22, 2010

Reflection on a Wednesday: F-Bombs, Control, and Other Reasons To Go Off

*names, details, etc. changed. . . . you know the deal!

"Going off": Not the ideal response you want from your patient. . . .

"going off:" 1. to lose all control in a fit of anger, often accompanied by harsh profanity, furniture throwing, and insults about the mother of the recipient. Can precede a physical altercation and may or may not end in handcuffs, an arrest, or both.

ex: "That man kept cutting me off when I was talking so I ended up going off on him right there at the bank teller window."

ex: "You better stop talking before I completely go off on you." (*note: "completely" going off is worse than just going off.)

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This woman (not this woman literally, but a woman) was going off on me in the hospital the other day. I mean completely going off. She was mad. Full-on, sho-nuff, cuss-you-out, tear-you-a-new-one, spit-flying-everywhere kind of mad. This woman was angry and hurt and frustrated and a bunch of other emotions that there probably aren't even words for. She had lost all control. But most of all, she had no control over an unfortunate diagnosis that had just been confirmed that day. And she was mad about it.

I know for sure that I wasn't rude or patronizing. I know I made an effort to be even more careful than usual, and auto-corrected my language as I spoke. I pulled out all the stops; using every single patient-doctor communication skill that I'd ever been taught. But none of them were working.

I kept track:

Three bullshits.
Five bitch-es.
Two chairs turned over.
And f-bombs too numerous to count.

I probably should have been scared or at least nervous. If a resident or medical student had been in this situation, I would have used my best sage attending voice to firmly remind them to remove themselves from the room. But I wasn't scared or nervous. Instead, I just felt sad.

I said to myself repeatedly what I always try to remember when a patient gets this kind of mad:

"This ain't about you."

Because it usually isn't. That kind of mad is reserved for people who are important to you. For most of my patients, that person is themself, not me. I don't waste any time getting on my high horse and thinking that I have that kind of power. Earlier in my training, I would internalize these exchanges and make it all about me. Next thing I knew, I 'd be neckrolling and raising my voice; reducing myself to an unprofessional, quivering blob of Jello. And so I've learned over time that in similar situations and in this situation, to remember that mantra: "This ain't about me."

It's about control. For this patient, the only piece of control remaining was in the decision to accept the diagnosis and treatment or not. The more I explained, the more she said derogatory things about me, the hospital and my "bullshit" diagnosis.

"You think you better than me. But you ain't shit, you hear me? Not shit." Wow.

"I don't think I'm better than you. I really don't, ma'am."

"You ain't the only one who knows stuff. Just because I don't have all them degrees don't mean I don't know stuff. I think this mess you saying is some bullshit. I'm going somewhere else. You think you can tell me anything 'cause I'm poor."

"Ms. Randall. . . .listen. . .I apologize if I have said or done anything that made it seem like I think I'm better than you. I care about you, Ms. Randall, and your income doesn't affect the way I see you or treat you." She rolled her eyes. I scoured my brain for those skills again. "Can we talk about how you feel a little more?"

"Fuck you. No." So much for the patient-doctor communication arsenal.

"Would you like for me to leave?"

"Yes. I'd like for you to get the hell out."

And that's what I did. I left the room. And gave her time.

A little later, one of the nurses came in to speak to her after I left. She began to cry. . .collapsing like a tired rag doll in the nurse's arms. She was shaking and wailing as the nurse consoled her, saying over and over again, "God, why can't I just catch a break? Why can't I just catch a break. . . .why, God?"

See? This was so not about me. This was about life and a hand that she wanted to throw in for another one. She was a single parent. She worked a minimum wage job. Her child's father was in the same place as her own father: state penitentiary. She could barely cover rent in an apartment located in one of the worst neighborhoods in Atlanta. She was losing money with every hour she was here and not at work. And now, she had just been handed a diagnosis that would surely cost her more money and more time. This hand sucked. Maybe even enough to warrant a few f-bombs if that's your thing.

Before I left the area, I slipped back into her room and carefully approached her. She looked up at me with apologetic eyes. I met her glance with a easy smile. No sorry required.

"Hey there," I said. At first, I was thinking about something more poignant like "You're going to beat this" or "You know, it's a blessing that this diagnosis was made early." I settled on the most vanilla thing I could muster.

"Hey. . ." she responded. Her voice was now hoarse. I missed the rest of the cry she had with the nurse, but it sounds like it was really therapeutic.

"Is now an okay time, or would you prefer for me to leave you alone for a little longer?"

"Naw. You okay. . . ."

"What can I explain better or what questions do you have for me?"

She took a deep sigh, and slowly started asking her questions and getting her answers. The rest of the encounter was, believe it or not, pleasant. I was happy to see her regain the control she so desperately sought earlier.

Final tally:

Seven bullshits.
seven bitch-es.
Two chairs turned over.
And f-bombs too numerous to count (one of which was followed by "you.")

2 comments:

Oh, you're such a good doctor. So respectful and professional of you to come back to see her. Any other un-experienced person wouldn't have come back. To the pt that meant a lot, meant that you understood where she was coming from and that it was the situation she was mad at, and not you. What an awesome example for residents and med students.

Welcome to Atlanta.

"Becoming is better than being." - Carol Dweck

Who me? I'm just glad to be here.

Honestly? I write this blog to share the human aspects of medicine + teaching + work/life balance with others and myself -- and to honor the public hospital and her patients--but never at the expense of patient privacy or dignity.
Thanks for stopping by! :)

What's the point?

"One writes out of one thing only--one's own experience. Everything depends of how relentlessly one forces from this experience the last drop, sweet or bitter, it can possibly give."

~ James Baldwin (1924 - 1987)

"Do it for the story." ~ Antoinette Nguyen, MD, MPH

Details, names, time frames, etc. are always changed to protect anonymity. This may or may not be an amalgamation of true,quasi-true, or completely fictional events. But the lessons? They are always real and never, ever fictional. Got that?